Sexual Compulsions

Sexual Compulsions and Sexual Addiction

Defining Paraphilias and Related Disorders

Sexual compulsions, know as Paraphilias, are socially deviant, persistent, highly arousing, sexual fantasies and urges that cause personal distress and/or social difficulties.
A paraphilia can revolve around a particular object (e.g., children, animals, feet, rubber) or around a particular act (e.g., exposing oneself, being physically injured).
A peron with a paraphilia is preoccupied with the object or behavior and requires it for sexual gratification. These "fantasies and urges" are not part of normal arousal patterns and are often described as "compulsions" by therapists, patients, and legal sources. In most cases, sexual activities outside the boundaries of the paraphilia are not arousing unless the person fantasizes about the paraphilia at the same time.
Sexual Compulsions are generally more common in men than in women.
Paraphilias are not the same as unwanted sexual obsessions, which cause anxiety rather than arousal.

Paraphilia-related disorders (PRD), also referred to as non-paraphiliac sexual addiction or sexual compulsions, are not well represented in the conventional diagnostic naming systems, though PRDs have been documented for some time. These disorders include socially accepted forms of sexual expression that become intrusive and excessive, accompanied by personal distress and significant impairment. Common PRDs include compulsive masturbation, promiscuity, pornography dependence, dependence on anonymous sexual outlets such as phone sex or Internet "cybersex," and other sexual compulsions. PRDs often meet psychiatric criteria for an impulse-control disorder, as these behaviors represent a failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or others.

Paraphilias and PRDs are not well recognized and can be difficult to treat for several reasons. Often people with these disorders conceal them, experience guilt and shame, have financial or legal problems, and can be uncooperative with medical professionals. In this age of computer technology, a patient can easily access materials related to his paraphilia from any Internet-capable computer, privately fueling a disorder that already is difficult to control.

Although paraphilias are rarely diagnosed in general clinical practice, a high prevalence is suggested by both the large commercial market in paraphilic materials (pornography and paraphernalia) along with the expansive network of 12-step and related recovery groups. Paraphilic behaviors lead to numerous problems, including shame, low self-esteem, relationship problems, divorce, sexually transmitted disease, unwanted pregnancy, incarceration, financial problems, child exploitation and abuse, occupational difficulties, and even suicide. It's not surprising that an estimated 70% of people with a paraphilia or PRD suffer from a depressive disorder as well.

Causes of Paraphilias and Related Disorders

Sexual compulsions and PRDs are complex psychiatric disorders therefore exact causes are not known, although many theories. Whether they represent an addiction, obsessive-compulsive disorder, impulse control disorder, or a pattern of hypersexualism is still a matter of controversy. Some have argued that since these disorders represent an ongoing pattern of uncontrolled sexual behavior, they should be viewed as an addiction, because like substance abuse, these consist of a pathological relationship with a mood-altering experience. Others have argued against this idea, instead describing paraphilias and PDRs as symptoms of an underlying obsessive-compulsive disorder (OCD).

Some authors have suggested that one way of looking at the OCD spectrum may be in terms of the dimension of compulsivity versus impulsivity. This perspective is based on the idea that sexual compulsions may reflect harm avoidance whereas impulsivity reflects risk seeking. Thus OCD falls on the compulsive end of an OC spectrum whereas impulse control disorders fall at the impulsive end, with disorders such as Tourette's disorder, trichotillomania and obsessive-compulsive personality disorder, which demonstrate characteristics of both, falling somewhere in between. However, this approach is overly simplistic; people with OCD may also have impulsive and even aggressive symptoms and people with impulse control disorders may have symptoms of OCD. OCD has been hypothesized to involve cognitive disinhibition. While OCD patients typically attempt to resist their symptoms, impulsive patients do not, and are only left feeling shame and regret after acting out.

Sexual Compulsions Hypothesized Neurobiology

In terms of neurobiology, the monoamines norepinephrine, dopamine, and serotonin are involved in the appetitive dimension of male sexual behavior in laboratory animals. Data gathered from studying the side effect profiles of antidepressant, psychostimulant, and neuroleptic drugs in humans suggest that changes to central monoamine neurotransmission can effect human sexual functioning, including sexual appetite. Monoamine neurotransmitters seem to modulate certain aspects of human and animal behavior including impulsivity, anxiety, depression, compulsivity, and social behaviors — dimensions disturbed in many paraphiliacs. Therefore, drugs that improve psychiatric disorders characterized by these symptoms, especially serotonin enhancing drugs, can also reduce paraphilic sexual arousal and behavior.

Medications for Paraphilias and Related Disorders

The treatment of men with paraphilias and PRDs has been challenging for patients and clinicians. In the past, surgical castration was advocated as a therapy for men with paraphilias, but it was abandoned because it is considered a cruel punishment and is now illegal in most countries. Psychotherapy, self-help groups, and pharmacotherapy (including the controversial hormone therapy sometimes referred to as "chemical castration") have all been used but are often unsuccessful. Here are some current drug treatments for these disorders.

Sexual Compulsions Hormone Drug Treatments

In humans, testosterone has a crucial role not only in the development and maintenance of male sexual characteristics but also in the control of sexuality, aggression, cognition, emotion, and personality. Testosterone is a major determinant of sexual desire, fantasies, and behavior, and it increases the frequency, duration, and magnitude of spontaneous and nocturnal erections. The deviant sexual fantasies, urges, and behavior of men with paraphilias also appear to be triggered by testosterone. Therefore, reducing testosterone secretion or inhibiting its action is believed to control these symptoms.

Antiandrogenic drugs such as medroxyprogesterone (also known as the long-acting contraceptive Depo-Provera) have been widely used as therapy in these men to reduce sex drive. However, their efficacy is limited and they have many unpleasant side effects, including breast growth, headaches, weight gain, and reduction in bone density. Even if compliance is good, only 60 to 80 percent of men benefit from this type of drug. Long-acting gonadotropin-releasing hormones, such as Triptorelin (Trelstar) which reduces the release of gonadotropin hormones, are also used. This drug is a synthetic hormone which may also lead to reduced sex drive.

Sexual Compulsions Psychoactive Drug Treatments

Selective serotonin reuptake inhibitor (SSRI) class of antidepressants such as fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and paroxitine (Paxil), have all been used to treat paraphilias and PRDs by reducing impulse control problems and/or sexual obsessions with some success. SSRIs work by selectively inhibiting presynaptic serotonin reuptake with minimal effect on levels of norepinephrine or dopamine.

Tricyclic antidepressants (TCA), such as imipramine (Tofranil) and desipramine (Norpramin), inhibit the reuptake of serotonin and noradrenaline, and can also modify the activity of glutamatergic neurons. This effect is caused by blocking the reuptake pumps in monoamine nerve synapses, extending the length of time neurotransmitters remain in the synapse and increasing their concentration. OCD responds preferentially to the TCA clomipramine (Anafranil), which is relatively selective for serotonin reuptake. Concern about these medications, however, persist as a result of their extensive side-effects, drug interactions, and toxicity when taken in excess.

Lithium The mood-stabilizing drug also known as Eskalith is typically used for the treatment of mania in bipolar disorder. There are some reports of reduced sexual compulsive behavior and a reduction in obsessive sexual thoughts in patients, which they attribute to the drug's enhancement of serotonergic functioning.

Anxiolytics are not considered a typical treatment for these type of disorders, however the efficacy of buspirone (BuSpar) has been clinically demonstrated.

Psychostimulants have been used recently to augment the effects of serotonergic drugs in paraphiliacs. In theory, the prescription of a psychostimulant without pretreatment with an SSRI might further disinhibit sexual behavior, but when taken together, the psychostimulant may actually reduce impulsive tendencies. Methylphenidate (Ritalin) is a type of amphetamine used primarily to manage the symptoms of attention deficit hyperactivity disorder (ADHD). Recent studies imply that methylphenidate may also act on serotonergic systems; this may be important in explaining the paradoxical calming effect of stimulants on ADHD patients. Amphetamine is also used medically as an adjunct to antidepressants in refractory cases of depression.

Sexual Compulsions Summary

Sexual compulsions, paraphilias and PRDs represent a fairly common disorder resulting in severe problems for patients as well as others who may be victimized by their behaviors. Antidepressants are an effective treatment and humane alternative to hormone therapy, or "chemical castration." Drug trials in people demonstrate that both TCAs and SSRIs are useful for treating paraphilias and PRDs. Evidence to date seems to indicate that paraphilias and PRDs may fall somewhere between an impulse control disorder and the OC spectrum. Augmentation with psychostimulants may be useful in certain cases. More research is needed to determine the best models, causes, and treatments of these problematic disorders.

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